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Research by charity Rethink Mental Illness last November found that 29 per cent of adults reported their mental health was worse compared to the start of the year.
Of those who said it was worse, 20 per cent reported suicidal thoughts, 12 per cent had experienced a crisis that needed professional help and 21 per cent had experienced panic attacks. The survey found that younger people struggled the most in 2022, with a third of 18-24 year olds reporting worse mental health.
Mark Winstanley, chief executive of Rethink, says: “We know that the pandemic had a massive impact on people’s mental health. Now the restrictions have eased, it feels mental health has taken a back seat, even though the link between mental health and money worries has come to the fore as the economic gloom settles over the country, with worrying numbers of people reporting suicidal thoughts or reaching crisis. It’s imperative that we focus on mental health during this cost of living crisis as we did during the pandemic, if not more.”
At Numark, patient services manager Lucy Morris says: “A report by the Money and Mental Health Policy Institute stated that this is having a negative impact on the mental health of 59 per cent of UK adults, with many feeling anxious and depressed. As such, it is important that pharmacy teams are aware of this fact and approach their customers with this in mind.”
The role for community pharmacy in mental health has grown since the pandemic. “Their main strength is around spotting early signs and symptoms as well as providing ongoing support for those who have a diagnosed mental health condition,” says professor Claire Anderson, president of the Royal Pharmaceutical Society. “Pharmacists and their teams in the community often see people on a regular basis and can notice and flag signs and symptoms of early mental health problems as well as deterioration or relapse.”
Focus on antidepressants
A study published in July 2022 by University College London reviewed research on the theory that depression is caused by an imbalance of serotonin. SSRI antidepressants temporarily increase the availability of serotonin in the brain. The researchers concluded that serotonin levels in blood or brain fluid between people with and without depression were not different, nor in the serotonin receptors.
“The serotonin theory of depression has been one of the most influential and extensively researched biological theories of the origins of depression,” says co-author Joanna Moncrieff, speaking in The Conversation. “Our study shows that this view is not supported by scientific evidence. It also calls into question the basis for the use of antidepressants.
“It is important that people know that the idea that depression results from a ‘chemical imbalance’ is hypothetical. And we do not understand what temporarily elevating serotonin or other biochemical changes produced by antidepressants do to the brain.”
Dr Adrian James, president of the Royal College of Psychiatrists, says: “Antidepressants are an effective, evidence-based treatment option that is recommended by NICE for people experiencing moderate to severe depression. Dozens of clinical trials have shown that they can help patients. However, they do vary in how they work.
“We would not recommend that someone stops taking their antidepressants based on any new studies. For many patients, this medication is part of a lifesaving treatment programme and coming off them suddenly can cause patients to suffer physical and mental withdrawal symptoms.”
NHS BSA figures show that an estimated 83.4 million antidepressants were prescribed in 2021/22 (up 5.07 per cent on 2020/21), with 8.32 million patients using them last year, an increase of 5.72 per cent. This is the sixth consecutive year-on-year increase in items issued and patients receiving them. The number of antidepressants prescribed has increased by 34.8 per cent compared with 2015/16 and the number of patients by 21.6 per cent.
So, with around one in six adults in the UK taking antidepressants, when should they be recommended? According to the latest NICE guidelines on depression in adults: treatment and management (2022), when discussing first line treatments for less severe depression, health professionals should consider the least intrusive and least resource intensive treatment first and not routinely offer antidepressants as first line treatment.
Choice of treatment, says NICE, should be based on the severity of the problem, past experience of treatment and the person’s preferences. When caring for people with depression, it is important to build trust and be non-judgemental, exploring treatment options in an optimistic manner. Clinicians should be aware of the stigma a depression diagnosis can carry, and that a patient’s mental health symptoms may make it difficult to access services. Be sure to respect confidentiality, and to offer up-to-date and evidence-based information.
If an antidepressant is prescribed, patients need key information, such as how they may be affected when they start taking them, the importance of following instructions closely, the need for regular monitoring and the impact of possible side effects.
New standards on depression
Adults who may have depression have a comprehensive assessment
Adults with a new episode of depression discuss full range of treatment options with their healthcare professional
Adults with depression who are at a higher risk of relapse are offered relapse prevention interventions
Adults with depression who are stopping antidepressant medication have the dose reduced in stages
Adults with depression from minority ethnic family backgrounds are supported to access mental health services.
Adults with depression who are stopping antidepressan medication have received a lot of media coverage. The aim of this new quality standard is to tackle withdrawal symptoms and to help people come off medication permanently.
At mental health charity MIND, Stephen Buckley, head of information, comments: “Unfortunately, we know that the vast majority of GPs don’t feel they really have the skills to help people taper the medicines. As such, GPs will need to receive proper support, resources and training to effectively help patients do this. It’s also important that patients are given enough information when they are first prescribed medication, so they understand the length of time for which they may be prescribed them, or potential difficulties they might face to stop taking them.”
Dr James says: “Anyone who is considering stopping their medication should speak to their doctor beforehand. GPs should be able to tell patients about the advantages and risks of reducing their dose so they can make an informed decision. The College has produced a resource for patients and carers on stopping antidepressants that offers information on how someone can taper their medication at a pace that suits them.”
What other treatments might help?
- Physical activity can promote wellbeing, says NICE, with the benefits potentially even more pronounced if it takes place outdoors
- Lifestyle changes like healthy eating, limiting alcohol use end getting enough sleep can be beneficial
- People may benefit from guided self help
- One-to-one or group talking therapy is useful. There are many different types, with the recommended one depending on symptoms and their severity. Local IAPT services can advise on which treatments require a referral from a GP or mental health team.
Role for community pharmacy
Professor Anderson thinks pharmacy teams are well equipped to deal with mental health problems. “Many pharmacists are adequately trained in this area to enable them to spot the early signs and symptoms of mental health problems, including changes in behaviour. Things like repeated requests for some online medicines such as anti-anxiety medicines can also raise red flags. The College of Mental Health Pharmacists provides training for pharmacy staff, and CPPE, HEIW and NES also provide a range of training opportunities.”
She believes community pharmacists can play a wider role in helping mental health patients discharged from hospital. “If hospital pharmacists are aware of potential mental health issues with a person in their care, they can alert the community pharmacist of this so they can provide support when the person is discharged,” she says. “Collaboration between hospital pharmacists and their community pharmacy colleagues when a patient is discharged helps ensure patients get the correct ongoing support in managing their medicines.”
Pharmacists can also signpost to GPs and support services if specialist help is needed. Their expertise in medicines is invaluable too. “Pharmacists can provide information about the risks and benefits of medicines, what a person can expect from the medicine and how best to take it, and information on how it might work alongside other medicines,” says Professor Anderson.
Dr James advises: “If a pharmacist is approached by someone who is struggling, they should signpost sources of support. Pharmacists can also advise people on how to take their treatments and what side effects they might experience.”
Ms Morris adds: “Pharmacies should focus on understanding more about mental health and raising awareness in their local communities. The key to this is offering support to customers.
“When people are experiencing mental health challenges, the way in which they think, feel and react and cope can be hard to deal with. As such, and in order to provide effective care, pharmacists need to deal with conversations with as much sensitivity as possible.”
For pharmacies who want to signpost themselves as mental health service providers, Ms Morris suggests: “A mental health promotion is a useful way to do this. With the option to tie campaigns into key dates in the mental health awareness calendar, such as World Mental Health Day, community pharmacies should order campaign resources. They should then engage their teams in the promotion and upskill their knowledge.”
An RPS policy sheet for pharmacy teams on managing mental health problems recommends assessing the nature and severity of symptoms before deciding on a management approach. “If symptoms are mild, the appropriate action may be simply to provide advice on positive behavioural change, lifestyle choices and self care,” it says.
The RPS also recommends forging referral pathways with local wellbeing services, mental health specialist teams and social prescribing services, adding that as demand grows, pharmacists’ contribution should be maximised by “improving current informal ways of working into more structured referral systems and working practices”.
“Anyone who is considering stopping their medication should speak to their doctor beforehand”
Funding for mental health services
We know that more and more people are seeking help for mental health problems and it’s good that people feel more able to talk. But are the services able to cope with increased demand?
In December, NHS England invested £10m in further support for mental health trusts to help those in crisis. Demand for mental health crisis services has increased by a third since before the pandemic. NHS mental health director Clare Murdoch says: “The NHS is helping twice the number of people experiencing a mental health crisis compared to five years ago, thanks to the rollout of 24/7 crisis support phone lines.”
However, while the Government announced £250m to support the NHS in discharging patients from hospitals, none of this money is allocated to support mental health services, bed discharges and address the long waits for a mental health bed faced by people who present at A&E.
“We’re disappointed to see a lack of recognition of the specific challenges the NHS faces in getting people who need mental health support into mental health beds,” says Paul Spencer, head of health, policy and campaigns at MIND. “We’d also question whether GPs, nurses and other community-based clinicians have the capacity to support more patients with complex mental health problems recovering in the community following discharge.”
Specialist mental health pharmacist training
The Specialist Mental Health Training Pathway has been introduced by Health Education England to support the development of up to 50 pharmacists working in new roles, with a commitment to providing up to 200 mental health pharmacist training places in 2023 and 2024.
The pathway consists of a tailored 12-month programme aimed at experienced pharmacists working in community mental health teams. There are up to 70 places in this year’s programme, which begins this Spring. To apply for a funded place, complete the online form.
Views from the P3pharmacy panel
I wouldn’t say this is a big category for us OTC, although of course we get plenty of prescriptions for mental health conditions. We might get customers who come in with a sleep issue and ask about remedies, but they don’t tend to want to talk about what might be causing this, or whether it could be a mental health issue. It’s quite tricky to bring this up with customers. We sell lots of Bach Rescue Remedy and also Kalms and Nytol day time remedies. In the Solgar range, 5-HTP natural serotonin does well too.
Hardik Desai, Ticehurst Pharmacy, East Sussex
Mental health is a hot topic, especially since the pandemic. Well has partnered with mental health charity Mind. Customers ask us if there is anything they can do without having to take prescribed medications. Questions about how they can help family members going through tough times and how long they can expect therapies to take to work are common. Post-pandemic, I think people are doing more to help themselves feel better and help others. Posters and POS around the store will help bring up mental health awareness conversations.
Marisa Maciborka, Well Pharmacy, Hirwaun
Mental health is a primary focus for us. The inextricable link between sleep disorders and mental health is a real concern. Our vigilance for mental health interventions is even more important since the launch of our sleep apnoea screening service. We are not often directly approached about mental health, but our training has increased our awareness to explore the possibilities when dealing with minor health requests. Mental health is much better recognised now as something pharmacies can get involved in.
Gareth Evans, Wansford Pharmacy, Peterborough
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